22
Vol. 66, No. 1 2015
Northeast Florida Medicine
CME
concluded that while the majority of maternal deaths could
not be avoided some could have been prevented by the phy-
sician(s). According to the study, the most preventable errors
are failure to adequately control bloodpressure inhypertensive
women, failure to adequately diagnose and treat pulmonary
edema inpreeclamptic patients, failure tomonitor/respond to
vital signs following Cesarean section (C-section) and failure
to control hemorrhage following C-section.
9
Steven L. Clark, MD, Medical Director of Women and
Newborn Services for HCA, stated, “The data showed the
individual causes of death to be very heterogeneous and that
the only cause of maternal death amendable to nationwide
systematic prevention efforts is pulmonary embolism. Preg-
nancy is a known major risk factor for venous thrombosis
and pulmonary embolism.”
10
Unlike nearly all other adult patients undergoing major
surgery, women undergoing C-sections have traditionally not
received prophylactic measures for the prevention of venous
thromboembolism (VTE) afforded similar surgical patients
who lack this risk factor. Between 1991 and 2003, the US
rate of severe complications and conditions associated with
pregnancywas 50 timesmore common thanmaternal death.
11
A review of settled obstetrical malpractice claims reveals
that adverse outcomes often result from under-responding to
abnormal vital signs, failing to recognize or notice indications
that complications occurred, and practicing in a state of denial.
It is imperative to establishprotocols with triggers for appropriate
responses. For example, adopting VTE prophylaxis measures,
coupled with comprehensive programs for identifying and
responding to hemorrhage can have a significant impact.
12
The bottom line in avoiding preventable pregnancy related
morbidity and mortality is that, in addition to the safe guards
discussed at the end of this article, the following should be
the standard of practice:
Acomprehensivehistory andphysical shouldbe takenwhen
care is initiated, which includes family and social history and
underlying medical conditions.
• Reassessment at the time of every office visit and
upon hospitalization is crucial.
• The “young and healthy” status of women in labor,
during delivery and post-partum should not exclude
requirement that physicians recognize and respond to
changes in a patient’s condition. Whether or not the
hospital has a process, the physician should require
that his/her patients be monitored throughout hos-
pitalization from admission to discharge, recogniz-
ing and responding as soon as a patient’s condition
appears to be worsening.
• Physicians who care for women with underlying
medical conditions should be attuned to the addi-
tional risks that could be imposed if pregnancy were
added, how to discuss these risks with patients, the
use of appropriate and acceptable contraception, and
pre-conceptual care and counseling. The attending
physician at delivery should communicate identified
pregnancy risks to all members of the health care
delivery team.
• The physician managing pregnant patients should
evaluate for, identify and respond to pre-existing med-
ical conditions such as hypertension, diabetes, morbid
obesity and advanced maternal age.
• The physician’s orders should identify specific triggers
for responding to changes in the mother’s vital signs
and clinical condition, and should stipulate interven-
tions for responding to the changes.
• VTE prophylaxis should be ordered for C-section
patients at risk for pulmonary embolism.
• Patients at high risk for thromboembolism should
be evaluated for low molecular weight heparin for
postpartum care.
5,6,7,8,9,10,11
Diagnosis Failures
Diagnosis errors are frequent and important, but can
be challenging to detect and dissect to ascertain how to
best avoid them in the future or the root causes. A study
conducted by a team of physicians led by GordonD. Schiff,
MD and representing Cook County John H. Stroger Hos-
pital, Rush University Medical Center, Hektoen Research
Institute, University of Illinois at Chicago, College of
Pharmacy and the University of Illinois at ChicagoMedical
School identified why diagnostic errors occur and what can
be done to avoid them.
13
The study, published in
Advances in Patient Safety: From
Research to Implementation
, describes what federally funded
programs have accomplished in understanding medical
errors and implementing programs to improve patient
safety during the last five years. This compendium, spon-
sored jointly by the Agency for Healthcare Research and
Quality and the Department of Defense (DoD)-Health
Affairs, catalogues a series of ideas for change.
13
• Reengineering follow-up of abnormal test results
• Standardizing protocols for reading x-rays and lab
tests, particularly in training programs and after hours
• Identifying “red flag” and “don’t miss” diagnoses
and situations
• Using manual and automated check-lists
